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Copyright 1999 The National Journal, Inc.  
The National Journal

February 27, 1999

SECTION: LOBBYING; Pg. 534; Vol. 31, No. 9

LENGTH: 2701 words

HEADLINE: Ignore Us, Please

BYLINE: Marilyn Werber Serafini


Tired of being on the defensive in Washington, the trade group
that represents HMOs is in New Hampshire and Iowa with a message
for GOP presidential candidates: Leave us alone.


     Bud Hawkins, vice president of National Aperture Inc., a
small, but rapidly growing, high-tech company in Salem, N.H., is
a recruit in an unusual battle being waged by the American
Association of Health Plans, a Washington trade association that
represents health maintenance organizations and other managed
care health plans. The AAHP has launched a campaign in New
Hampshire and Iowa aimed at convincing Republican presidential
candidates to ignore (that's right, ignore) a supposedly popular
issue: giving more rights to patients in managed care plans. And
Hawkins, who's worried that government mandates would make health
care more expensive, is happy to oblige.

     ''Any increase (in premiums) comes out of our bottom line
and inhibits our growth,'' he said. ''We can't expect employees
to pick up higher costs in a tight labor market.'' After
receiving a mailing from AAHP on the issue, Hawkins agreed to
participate in a press conference urging presidential candidates
not to champion managed care reform.

     The AAHP campaign is, to understate the case, atypical of
the usual form of issue activism in New Hampshire and Iowa.
Normally, groups try to get presidential candidates interested in
promoting their issues, on the theory that a little attention by
a presidential candidate can leverage a lot of attention by an
approving and concerned public, which can in turn leverage the
legislative attention of Washington. The AAHP effort, by
contrast, is making the case that presidential candidates should
ignore the issue of managed care regulation because the public
actually doesn't care about it. If the presidential candidates
ignore it, the theory goes, so, too, will Congress.

     Second, business associations in the past have not tended
to get involved in early primary and caucus states, preferring to
concentrate their lobbying in Washington. AAHP, tired of being on
the defensive in Washington, decided to take a new tack. (Still
fresh in the health industry's mind is the health reform fight of
1993-94. While industry slept, consumer groups helped make health
reform a major issue in the 1992 presidential campaign; industry
eventually succeeded in killing the Clinton plan, but only after
tens of millions of dollars in expenses and a bruising battle.)

     ''We're trying to take lobbying into the 21st century,''
said Mark Merritt, vice president and chief of strategic planning
at AAHP. ''The days when you could sit down with someone's chief
of staff and sip martinis are gone. We're trying to impact a
broader debate. If you can drive news in New Hampshire, you drive
it nationally. It's the wave of the future.''

     So how do you make the case that an issue should be
ignored? One way is to take a poll. In January, AAHP paid
Republican pollster Whit Ayres to question 300 likely Republican
primary voters in New Hampshire and 300 likely Republican voters
in Iowa on their concerns about health care. (AAHP chose to
ignore Democratic voters and candidates because Democrats tend to
favor more regulation of managed care. Merritt said it would be a
waste of time to try to influence Democrats on the issue.)

     The poll found that likely Republican voters were
somewhat concerned about rapidly rising health care costs and the
growing numbers of uninsured. But they weren't much concerned at
all about managed care reform and didn't think candidates should
focus on it. Indeed, 85 percent of Republicans in managed care
plans said they were happy with their coverage. AAHP took the
results and pitched them to political reporters in New Hampshire
and Iowa. To entice the reporters, AAHP also asked horse-race
questions of the Republican voters. (Elizabeth H. Dole and George
W. Bush were their favorites.) That's what interested Garry
Rayno, who covers the statehouse for Foster's Daily Democrat in
Dover, N.H. Rayno said he went to Ayres' press briefing to get
the horse-race numbers, but he ended up writing a story that
focused on the poll's health care findings--exactly what AAHP

     ''We're viewing lobbying as totally different than it is
viewed by 99 percent of the organizations in this town,'' boasts
Merritt. ''If we focus on the campaign when the voters do, in the
fall of 2000, there's no way we can win,'' he said. At that
point, he added, ''the candidates have already figured out which
issues they're going to use. The way to change issues is now,
with a two-year campaign.''

     The GOP presidential candidates are receptive now,
Merritt said, because they are unfamiliar with New Hampshire and
Iowa. ''They're used to being lord and master of where they're
from. They know the state in and out. But when it comes to New
Hampshire and Iowa, they're getting their sea legs. They will
meet with us. They will take our polling information.''

     But not everyone is impressed. ''They've made a big
miscalculation,'' said Ronald Pollack, president of Families USA,
a Washington-based consumer group pushing for legislation to
expand the rights of managed care patients. For one thing,
predicted Pollack, Congress will enact managed care reform before
the presidential election, making AAHP's campaign largely
irrelevant. For another, said Pollack, by targeting Republican
presidential candidates, AAHP is preaching to the choir.

     ''The issue of health care in general, and patients
rights in specific, is never an issue which the Republican
leadership has wanted to talk about. That's going to be true of
most of the Republican candidates for President,'' Pollack said.
''We've been silently amused by (AAHP's) effort. It will be a
significant expenditure that's a very misplaced expenditure.
We're happy they're doing that, because they're missing the

     Some Republicans are also critical. Paul Young, director
of northeast operations for Republican Steve Forbes' political
organization, Americans for Hope, Growth, and Opportunity, said
that even without AAHP's efforts, Republican candidates aren't
likely to bring up HMO reform. Young said he never saw AAHP's
polling information.

     Steve Duprey, New Hampshire's state GOP chairman, offers
a different criticism. HMO reform is already a big issue in New
Hampshire, he said, because Democratic Gov. Jeanne Shaheen, who
was just re-elected, made it one of her top three campaign
issues. He said the issue helped Democrats gain control of the
state Senate for the first time since 1912.

     ''Every one of our 10 (presidential) candidates will go
into a living room party and I guarantee they'll get a question:
'What can you do to make HMOs work better?' Every candidate will
address it. They won't ignore it, because it's already such a big
issue in New Hampshire. They shouldn't ignore it. They are
whistling through the graveyard if they think voters are not
going to talk about this issue.''

Fighting Politics With Politics

     AAHP has a lot to lobby about. For several years now, the
HMO industry has been under attack, in state capitals and in
Washington, from legislators inundated with complaints about
managed care. Many states have passed laws requiring health plans
to pay for more hospital days for certain procedures, prohibiting
them from denying most emergency room coverage, and requiring
independent grievance procedures.

     Congress has passed a few bills as well, but it got
bogged down last year when it tried to pass comprehensive
legislation. Republican leaders in both the House and the Senate
have promised to push through legislation this year; members of
both parties have already introduced many bills. Some would go as
far as allowing patients to sue their health plans for denying

     AAHP responded to some of the earlier legislative threats
in Congress by promising voluntary industry standards. For a
while, it even looked as if some health plans would support a
limited federal bill. But the association is now tougher than
ever in its opposition to any legislation.

     Some health care policy observers warn that this stance
may hurt the health plans in the end. If AAHP doesn't work with
Congress to achieve compromises on the legislation, they say, the
group could lose the ability to soften the bill.

     Karen Ignagni, AAHP's president, counters that her group
is trying to make a difference in Washington, and that it will
continue lobbying on Capitol Hill, running ads in Washington, and
bringing in member health plans and supporters to spread the
word. But during the past two years, Ignagni has also carried out
a plan to transform the AAHP into more of a political
organization. ''We're into a political debate that deserves a
political approach,'' she said.

     AAHP will have a $ 20 million budget in 1999--the same
amount it had in 1998. But Ignagni is rechanneling funds to
grassroots and media activities. ''The whole question of how we
advocate on behalf of our members as an association has evolved
throughout the 1990s. We're no longer approaching our
responsibility as going up to the Hill, lobbying, and doing an
occasional research report,'' she said.

     Ignagni's first step was to bring on a political
operative (Merritt, who was presidential hopeful Lamar
Alexander's press secretary in 1996) to help the association
become more politically savvy. Ignagni hired several more
strategists, who went to work quickly to strengthen existing
grass-roots alliances and form new ones. They used information
about the effects of proposed health plan mandates on employment,
local economies, and employees to find allies outside of
Washington. The idea, Ignagni said, is to ''drive grass roots,
which drives the press, which drives politics, and gives more
energy and exposure to grass roots, where the whole thing begins

     In New Hampshire, in addition to commissioning a poll,
AAHP has enlisted Brian McCabe to serve as its political
consultant. McCabe, who was executive director of Bob Dole's New
Hampshire campaign in 1996, and is now president of McCabe
Consulting Group, lined up two small-business owners, including
Hawkins, to participate in a press conference at which Ayres
released the poll findings.

      AAHP has already gotten some positive feedback. After it
released the poll results in New Hampshire and Iowa, a handful of
newspaper stories appeared in each state, and a lengthy piece ran
on National Public Radio and in Legal Times.

     But what excited AAHP executives most is what happened
next. Merritt started getting calls from campaign workers and
consultants who wanted to see the full package of information,
health care stuff and all. ''I guarantee that that poll was in
every (candidate's) briefing book for January or February,'' said
a GOP campaign consultant. ''If you're preparing a candidate to
go up for their first trip (to New Hampshire and Iowa), they need
to know this kind of information.''

     Merritt said that AAHP will follow up with television and
radio ads in both New Hampshire and Iowa, and that it will try to
build and maintain a relationship with political reporters in the
two states. Ignagni said that business leaders in other states
are calling her to ask if the AAHP can bring the program to their
states. She may do that.

     A linchpin of the effort is the poll, which shows,
according to Merritt, that managed care regulation ''is a loser
issue to get involved in.'' In New Hampshire and Iowa, most GOP
respondents said that they placed greater weight on issues other
than HMO reform, such as character, and positions on taxes and
education. Between 60 percent and 70 percent of respondents in
both states said that they would oppose more government
regulation of employer-provided health care plans if it raised
health care costs by $ 25 per month. And in Iowa, about 70 percent
of respondents said that they think most politicians who make an
issue of regulating HMOs are ''just trying to gain political
advantage for elections,'' as opposed to being serious about
protecting consumers.

It's All in the Question

     But some question AAHP's survey results. ''It's how you
talk and how you ask the question,'' said Mollyann Brodie, vice
president for public opinion and media research at the Henry J.
Kaiser Family Foundation in Menlo Park, Calif. Kaiser has
conducted similar polls of Republicans and Democrats, but has
emerged with significantly different findings. The reason, Brodie
says, is that while AAHP asked about goals for the nation, Kaiser
asked about personal concerns.

     ''If you ask them if they're personally concerned for
themselves and for their families, it's a more important issue,''
she said. ''We asked them how concerned they were about the
following issues for them and their families. Sixty-nine percent
said they were concerned about protecting patients' rights in
HMOs and managed care.''

     Stephen Gorin, president of the New Hampshire Citizens
Alliance, a group that sometimes works informally with the
Washington-based Families USA, says his organization will be
trying to make managed care reform an issue in the presidential
campaign, regardless of AAHP's efforts. ''I'm surprised that
they're here, but we welcome the challenge,'' said Gorin. ''I'm
one of the leaders of the opposition, and we think public opinion
is on our side.''

     After AAHP released its poll results, Gorin issued a
press release responding that the AAHP poll was misleading. Some
of that information made it into the newspaper stories.
Specifically, Gorin challenges the poll's assumption that a
patients' bill of rights could raise the health care costs of
employer-provided health coverage by $ 25 a month, per person.
Gorin's press release cites estimates from the Congressional
Budget Office that the Patients' Bill of Rights sponsored last
year by Sen. Edward M. Kennedy, D-Mass., and Rep. John D.
Dingell, D-Mich., would raise those prices only about $ 2 per

     Moreover, he said that AAHP made a mistake in limiting
its polls to potential GOP primary voters. ''Those are the people
you'd tend to assume are the most conservative Republicans. It's
not surprising that a fair number of them would oppose a
patients' bill of rights.''

     Gorin and Pollack intend to raise the visibility of
health care issues in New Hampshire with their own initiative
called New Hampshire Asks. (They're helping to start a similar
initiative in Iowa, too.) The idea is to pick two important
health care issues and raise them repeatedly when candidates come
to the state.

     The effort is expected to be similar to one in 1992 when
some 40 organizations agreed to ask candidates questions about
health care reform. ''We repeated them over and over again. The
Concord Monitor called us a Greek chorus,'' said Gorin. ''We
think we had some impact, particularly with the Democrats. We're
bipartisan, but certainly in '92, it was the Democrats who were
listening to us. We helped push Clinton toward taking a stand.''

     Gorin acknowledges that AAHP will probably have some
effect on the HMO debate this time around. ''Their good fortune
is that they have the money to run the kind of campaign we would
like to run.''

     Merritt insists that the AAHP's approach is the wave of
the future for lobbying. ''The congressional legislative agenda
is increasingly dominated by the presidential campaign,'' he
said. ''Both parties see the outcome of the presidential contest
and the issues debated as the single most important (factor
determining) who controls Congress after 2000. So, this is our
way, and an efficient way, to get an awful lot of bang for our

LOAD-DATE: March 01, 1999

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